Report reveals Oregon hospital errors

Between October 2008 and June 2010, nearly 100 Oregon patients covered by Medicare fell down or suffered bodily trauma while receiving hospital treatment.

Another 53 patients contracted urinary tract infections, while 28 patients experienced vascular catheter-associated infections while under hospital care. Physicians also left foreign objects in five Medicare-covered patients during that time.

The errors came to light last month in a report by the Washington, D.C.-based Centers for Medicare and Medicaid Services. The report, which measured eight error categories at 4,700 hospitals nationwide, tracked “hospital-acquired conditions” among Medicare patients. Hospitals must pay millions to bear the brunt of the error-related costs.

In 2014, Medicare will begin penalizing hospitals in the bottom 25 percent nationwide, or those with the worst error records, at 1 percent of their Medicare reimbursement.

The U.S. Health and Human Services department, which oversees the center, made the data public as it seeks more transparency of health care quality and pricing data.

Area hospital administrators say while they welcome the quality management efforts, the Medicare data doesn’t provide the most reliable information.

“We’re very much in favor of transparency: It’s very helpful to discuss the data intelligently and rationally,” said Dr. Chuck Kilo, Oregon Health & Science University’s chief medical officer.

Hospitals can use the Medicare data in a more global manner, said Bethany Higgins, an administrator with the Oregon Patient Safety Commission.

“It could help them inform and prioritize their own improvement efforts, and that can help translate to their broader population,” said Higgins, whose group also released its own hospital quality report in April.

All told, 195 errors were made at 32 Oregon hospitals. Eleven Portland-area hospitals made a total of 76 errors during the study period.

Most hospitals didn’t fare well in the falls-and-trauma category. Twelve patients fell at Providence’s Portland Medical Center, a rate of 1.463 per-1,000 patients. The rate was nearly triple the national average.

Providence has already begun concerted efforts to prevent falls at each of its Oregon and Washington facilities. For all patients, Providence’s hospitals currently rank in the 25th best percentile in terms of patient fall rates, said Kris Kalman-Yearout, a Portland-based nursing team leader.

Oregon’s hospitals did log excellent scores in two of the study’s eight categories. No hospitals were responsible for air embolisms, in which potentially fatal air bubbles creep into intravenous lines. None of the state’s Medicare-providing facilities gave patients the wrong blood types.

Mid-Columbia Medical Center posted the state’s single highest error-rate in any one category. Three patients experienced falls at the small hospital, giving it a 2.193 per-1,000-patient error rate.

In the Portland area, Legacy’s Emanuel Medical Center recorded a 1.868 per-1,000-patient error rate in terms of catheter-associated urinary tract infections. The national average was 0.316 per-1,000 patients.

Legacy’s high catheter infections numbers stem from the hospital’s patient base, which consists of a large number of burn and trauma patients who are susceptible to the condition, said Jodi Joyce, Legacy’s vice president of quality and patient safety.

Such patients, some of whom cannot use the bathroom on their own, require catheters for longer periods of time. The longer they’re equipped with a catheter, the greater the chance that they’ll contract urinary tract infections.

Legacy had targeted reducing the number of such infections long before the Medicare report was released. Among all Legacy patients, catheter-related urinary tract infections have dropped by 52 percent over the last three years, said Joyce.

“These are priorities for us: They represent harmful events that we never want our patients to experience,” she said. “The challenge is that some of these (conditions) aren’t completely preventable.”

The survey met with resistance from national hospital groups that argued it doesn’t present a complete care picture. The groups, including the Washington, D.C.-based American Hospital Association, further contend the data doesn’t gibe with other national quality measures.

At the same time, the data isn’t adjusted based on the type of patients the federal group studied. Medicare patients, for instance, often check into hospitals with conditions other than those for which they’re being treated.

Those ailments can make them more susceptible to such hospital-acquired conditions as catheter-caused infections, critics say.

Diane Waldo, director of quality and clinical services for the Oregon Association of Hospitals and Health Systems, said her group’s members expressed concerns about the report before it was released.

“(The Medicare agency) hasn’t been forthcoming about how they calculated or verified it,” she said.

Waldo added that the data was presented in a hard-to-read Excel format.

“It makes you wonder how ‘Joe Consumer’ can use it in a meaningful way to make health decisions,” she said.

Fast Facts

The Oregon Patient Safety Commission issued its own report May 26 detailing adverse events at 58 Oregon hospitals during 2010.

Unlike the Medicare and Medicaid Services report, which focused only on patients covered by Medicare, the Patient Safety Commission tracked all patients who entered acute-care hospitals.

Administrator Bethany Higgins confirmed that 34 patients died during 2010 as a result of adverse events.

All told, the group counted 136 adverse events during 2010.

Fast Facts

To view a searchable database of local hospital errors, go to www.portland.bizjournals.com.

Falls account for large number of medical errors

The Centers for Medicare and Medicaid Services error-rate report, issued in May, found that 97 Oregon Medicare patients were subject to falls or similar accidental trauma.

Such accidents, by far, comprised the most errors among Oregon hospitals in the report, which studied the period between October 2008 and June 2010. The report found that the rate of patient falls was also the highest among eight types of incidents that hospitals must report to the federal government.

Area hospital leaders say it’s their top priority to reduce such incidents. Hospitals within Legacy’s system are encouraged to take several precautions, especially when patients are bedridden or taking medications that might make them dizzy:

• They outfit patients who are susceptible to falls with red socks. The socks demonstrate to providers that they should caution when those patients attempt to move around.

• They must keep rooms clutter-free.

• They must remove any of the room’s unnecessary equipment.

• They must keep beds in the lowest possible position.

Providence’s health centers are also taking steps to reduce its region-worst 1.463 per-1,000-patient error rate in the falls and trauma category. A patient-safety team has ordered beds that are lower to the ground than typically lofty hospital roosts. Providence also uses bed exit alarms that alerts caregivers when patients are arising.

Caregivers also make rounds at least every one to two hours to help patients use the rest room or move objects within an arm’s reach.

“People are at higher risk for falling in the hospital,” said Kris Kalman-Yearout, a Providence nursing team leader. “They’re in an unfamiliar location and might be on pain medications. And if you have issues with getting up and down, and being mobile, in the first place, it’s easier for things to get in your way.”

Providence’s systems have helped the company record overall lower fall rates than the Medicare center study indicated, hospital leaders said.